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Prehosp Disaster Med. 2009 Nov-Dec;24(6):529-34.

Paramedic knowledge, attitudes, and training in end-of-life care.

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Keck School of Medicine, University of Southern California, Los Angeles, California, USA.



Paramedics often are asked to care for patients at the end of life. To do this, they must communicate effectively with family and caregivers, understand their legal obligations, and know when to withhold unwanted interventions. The objectives of this study were to ascertain paramedics' attitudes toward end-of-life (EOL) situations and the frequency with which they encounter them; and to compare paramedics' preparation during training for a variety of EOL care skills.


A written survey was administered to a convenience sample of paramedics in two cities: Denver, Colorado and Los Angeles, California. Questions addressed: (1) attitudes toward EOL decision-making in prehospital settings; (2) experience (number of EOL situations experienced in the past two years); (3) importance of various EOL tasks in clinical practice (pronouncing and communicating death, ending resuscitation, honoring advance directives (ADs)); and (4) self-assessed preparation for these EOL tasks. For each task, importance and preparation were measured using a four-point Likert scale. Proportions were compared using McNemar chi-square statistics to identify areas of under- or over-preparation.


Two hundred thirty-six paramedics completed the survey. The mean age was 39 years (range 22-59 years), and 222 (94%) were male. Twenty percent had >20 years of experience. Almost all participants (95%; 95% CI = 91-97%) agreed that prehospital providers should honor field ADs, and more than half (59%; 95% CI = 52-65%) felt that providers should honor verbal wishes to limit resuscitation at the scene. Ninety-eight percent of the participants (95% CI = 96-100%) had questioned whether specific life support interventions were appropriate for patients who appeared to have a terminal disease. Twenty-six percent (95% CI = 20-32%) reported to have used their own judgment during the past two years to withhold or end resuscitation in a patient who appeared to have a terminal disease. Significant discrepancies between the importance in practice and the level of preparation during training for the four EOL situations included: (1) understanding ADs (75% very important vs. 40% well prepared; difference 35%: 95% CI = 26-43%); (2) knowing when to honor written ADs (90% very important vs. 59% well-prepared; difference 31%: 95% CI = 23-38%); and (3) verbal ADs (75% very important vs. 54%well-prepared, difference 21%: 95% CI = 12-29%); and (4) communicating death to family or friends (79% very important vs. 48% well prepared, difference 31%: 95% CI = 23-39%). Paramedics' preparation in EOL skills was significantly lower than that for clinical skills such as endotracheal intubation or defibrillation.


There is a need to include more training in EOL care into prehospital training curricula, including how to verify and apply ADs, when to withhold treatments, and how to discuss death with victims' family or friends.

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